19 Plain Film X-Ray Reporting in Orthopaedic Patients: A Reaudit in a District General Hospital

Abstract

Abstract Aim To assess clinical evaluation of plain film x-rays requested for patients in the orthopaedic department (clinic and ward) Standards: Ionising radiation (medical exposure) regulations irmer 2017 procedure j: recording clinical exposure, national guideline and local guidance is in keeping with irmer and good clinical practice. Method 50 plain films of randomly selected (using random number generator) who had attended new patient fracture clinic and ward. An initial audit was done in June and an reaudit in September. The radiology system, clinical notes and clinic letters were reviewed to obtain the relevant data. Results Audit: 20 films were documented 30 were not documented Reaudit 32 films were documented by referring clinician 18 films were not documented by referring clinician Audit: Clinical evaluation documented 18 Clinical evaluation not documented 32 Reaudit: Clinical evaluation documented - 29 Clinical evaluation not documented - 21 Discussion Whose responsibility? Radiographs commented on in trauma meetings not documented. New radiographs not commented on in clinic. Limitations - access to more notes from ward. Conclusions As outlined in guidance orthopaedic and fracture clinic plain films should be reported by referring clinician or their team. Currently this is being done 64% of the time, significant improvement was seen. This may have medicolegal consequences as it does not follow GMC guidance for good medical practise. Recommendations Clinicians to specifically dictate x-ray findings in fracture clinic. Junior staff to take responsibility for documenting x-ray findings as discussed with senior clinicians for trauma patients. Junior staff to review post-op x-rays for all patients and to document.